Wiki E/M Documentation Requirements

[kristinab]

I'm needing some help. I have a doc in our office that keeps using the words, "there is no change in HPI or PE, please refer to previous dictations. I have found documentation showing that if nothing has changed in the ROS or PFSH that you can document nothing has changed and the date. Is there anywhere that states what can and cannont be documented in the pt's dictation for the HPI and PE.? I feel that if he is using that sentence then it's going to look like like he's duplicating the service from the prior visit. I just need to find the documentation to support whether it can or can't be done.

 

[SuzanBerman]

I know I actually have a site where it is illustrated, however, I've been searching and haven't yet found it.

However, in the meantime, the Documentation Guidelines do a lot in this regard. They mention when things CAN be referenced. And my NOT mentioning when things CANNOT be referenced, one should understand that to mean that it cannot be referenced. I cut the below passage out of the DG for 1995. It was clearly stated in the history section and purposefully not in the exam section as it does not pertain.

A ROS and/or a PFSH obtained during an earlier encounter does not need to
be re-recorded if there is evidence that the physician reviewed and updated
the previous information. This may occur when a physician updates his or
her own record or in an institutional setting or group practice where many
physicians use a common record. The review and update may be documented
by:
• describing any new ROS and/or PFSH information or noting there
has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH.

I hope this helps to some degree.

Suzan Berman CPC, CEMC, CEDC